I'm Dr. Bonnie Jo, and we will be starting our case-based review session on post-surgical breast. I'm going to be doing the first part, which is post-lumpectomy. So just to go through the session, we're going to go through the learning objectives and lecture topics in this order. So number one, reviewing expected imaging findings in the post-surgical and post-radiotherapy breast. Two, review imaging findings of breast augmentation, including implants, breast implant removal, and how to evaluate implant integrity. I'm looking forward to that. That's always a challenge. And then most importantly, number three, recognize the imaging findings of breast cancer recurrence. So starting off with the post-radiotherapy, post-lumpectomy breast. Our first case, 71-year-old female patient. She had a lumpectomy on the right about five years ago for DCIS. We did a diagnostic mammogram. Here are right breast images. Left breast was normal. So how would you interpret this exam? Well, let's go through some of the findings. There are surgical clips marking the lumpectomy cavity. There's architectural distortion. And then the question is, is that a mass, or there's certainly density at the lumpectomy bed, and it looks like there's some calcifications. So given this information, what BI-RADS would you give this breast, or this patient? Negative, benign, probably benign, suspicious, or highly suggestive of malignancy. I think with that information alone, first time at your practice, you have to call it suspicious and work it out. So what we really need, of course, are her prior comparison exams. If you are seeing a patient for the first time and they've had breast surgery, ideally you're going to get those priors and schedule her exam for after the time when you think you can get the priors to compare, because it's really hard to be faced with a post-surgical breast and not have any prior comparisons. So here are priors. Fortunately, she did have these prior exams. This is two years prior compared to current. I'm just showing the CC view for ease of comparison. And then here is four years prior. So this is very reassuring and helpful, hopefully. So now, with that added information, when faced with the interpretation for this case, we essentially have a surgical cavity that's looking better and better. And so this is where you can call this benign, as an assessment showing, even though this scar seems to be mimicking a spiculated mass, what we found out was that at baseline she had a really large seroma. And talking to the surgeon, she also had infection and had a very protracted recovery. So this ugly-looking scar was likely due to that very protracted period of healing. And thankfully, this isn't the typical appearance of a post-lumpectomy patient. But in this case, this is what happened. And so with the information that she was improving, they were able to call it benign. Patient actually did get a stereotactic biopsy, but it was for calcifications that were developing in her lumpectomy bed. And so for added reassurance, in case you were still worried we might have missed a cancer here, the biopsy clip is in that lumpectomy bed, and we found benign post-surgical changes. So the moral is, comparison with priors avoids unnecessary workup in biopsy. So in general, post-surgical breast, you want to try to get those prior exams. Okay, here's a companion case. This is a 60-year-old woman who had a right lumpectomy. Here I'm showing a series of images, one year prior, six months prior, and current. This is the evolution of lumpectomy scar and fat necrosis. I'm going to do photographing enlargement, just so you can see that typically we like to watch that lumpectomy cavity shrink over time and also become less dense over time. So that is a normal appearance. And this brings me to our UCSF surveillance protocol. If you notice, we did have a six-month interval there. And that's because we follow these patients every six months after lumpectomy. The rationale is that patients with a personal history of breast cancer are at higher than average risk. We do believe in annual screening for average risk patients. And so for our breast conservation patients, we are recommending screening the ipsilateral, that's the cancer-conserved breast, every six months for five years. And this is a protocol that was started by Dr. Sickles a long time ago. This also allowed us to write up our outcomes. So this has been published. This was published in 2012 in Radiology. And it talks about the benefit of doing semi-annual ipsilateral mammographic surveillance. Just to share some of that data with you, we had about 2,300 women who were retrospectively identified. This covered 1997 to 2008. So this was over a decade ago. Over 10,000 mammography exams. Most of our patients were compliant with this six-month protocol. About 15% were at the 12-month interval. And the groups were equivalent, as far as we could tell, based on age and family history. We had 114 recurrences, a rate of about 1% per year. And just to show you the data for invasive cancers, so this is just the invasive recurrences. If you looked at semi-annual versus annual interval, stage one cancers, 90% if caught on the semi-annual interval versus 64% if caught on the annual. So as expected, recurrences were less advanced in women who were compliant with the six-month protocol versus if we found their recurrence on the annual. And so this is why we continue this protocol today. Okay, moving on. This is a 43-year-old woman. She had a right lumpectomy for invasive cancer, negative margins, negative sentinel lymph node biopsy, and she had whole breast radiation. This was about three years ago. So here is her current exam. Again, left breast was normal. Give you a moment to look at her CC and MLO. And then we're going to focus on just the MLO view in this case. There is her lumpectomy scar. It's not marked by surgical clips in this case, so the surgeons don't always leave clips behind. She also has diffused skin thickening. And then there's this generalized edema of the breast, or as my mentor, Dr. Monzies, used to say, it looks like she has CHF of her breast. So this is a chance for the audience to respond to this question. What do you think is the cause of this skin thickening? Is it radiation? Is it recurrence? Is it mastitis? Is it lymphedema? I should point out that actually any of these are possible, and you really need some more information because in the right clinical setting, this could be mastitis. If the patient's also complaining of arm swelling, it could be lymphedema as well. And certainly recurrence is something we're always concerned about, but since that's not the topic of my talk, probably no one answers recurrence, right, because you know that's coming later. So here's the current and the prior. So of course, we want prior exams. The findings were stable to improved compared to the prior exam, again, supporting that this is the usual typical post-radiation changes. Also, very importantly, the patient's doing fine. She has no symptoms. So in an asymptomatic patient, yes, you can call this radiation. So this is BI-RADS 2 benign post-surgical scarring, post-radiation skin thickening, and edema. Now, for those who are still concerned, here is her MRI six months later. Similarly, we see a surgical scar, and we see persistent skin thickening. Here's the subtraction to prove to you there was no appreciable enhancement, so all very reassuring and supporting the fact that this is most likely her expected post-radiation changes. Now, for those of you with eagle eyes, or just in case you didn't notice this artifact, I'm going to show it to you a different window level, okay? There's some susceptibility there. Now, this is true susceptibility. It's not a FATSAT failure problem or homogeneity problem, because here's her T1. So the T1 non-FATSAT really highlights susceptibility artifact. I don't know if anyone's seen this before or know what this is. Oh, thank you for the dimming of the lights. Okay. So this is something that I learned about, and it is superparamagnetic iron oxide particle injection that is used for sentinel lymph node biopsy. So this is something our surgeons were doing. The iron deposits in the sentinel nodes, and then they can detect these sentinel nodes in the axilla using a magnetometer. It also stains the nodes a dark color. So this avoids the need for a separate radioactivity injection and a separate visit to nuclear medicine, so they were doing this in pre-op before they took the patient to surgery. So the problem is that these SPIO particles do remain in the breast tissue, and in fact this is a scan obtained over three years after the initial surgery and injection. So this artifact persists, and the problem for us is that it's non-diagnostic in the areas affected by artifact. So this is something we have brought to the attention of our surgeons, and very importantly, if they're planning a lumpectomy and this patient's a candidate for breast MR surveillance, we don't want to use this technique for their sentinel lymph node biopsy. Okay, here is another surveillance MR in a patient who's had a lumpectomy. I'm going to show you a series of images. This is the T1 post-contrast. Lumpectomy was on the right. Hopefully it's pretty obvious where the cavity is. So here's a series of images showing her lumpectomy cavity. There is the subtraction. So there's a little bit of faint enhancement around the cavity, and if you're wondering what's in the cavity, here's the T1 non-FATSAT to help you out. So just to remind you, it's bright on the non-FATSAT, and then on that fat-suppressed image it was dark, and it's not enhancing. So this is a typical appearance, another appearance of fat necrosis. The fact that there's a little bit of enhancement is okay, as long as it's not asymmetric or nodular enhancement. So if we see any nodularity or if it's really, really brightly enhancing or showing washout, then we might question it. But if it's kind of a faint, persistent enhancement, and especially if you have priors and you're showing that it's stable and improving slowly over time, that's okay. So this is just fat necrosis. It's a benign finding. And then the other thing I want to point out in these cases is that the BPE can be asymmetric. So there is BPE on the left breast that I would probably call moderate. So left side is moderate, and the right side was minimal. This is just the mammogram showing that she had right lumpectomy on the right, and she also had whole breast radiation. That's part of the breast conservation. So the moderate BPE on the left, minimal on the right after whole breast radiation is an expected finding. It's a normal finding. So you can have asymmetric BPE when you had whole breast radiation. And so that's okay. So you don't need to call the left side abnormal. Okay, moving on to another case. This patient had left lumpectomy, and this came from an outside facility. So here is her mammogram, and I wanted to call your attention to the metallic things in her lumpectomy bed, okay? Again, this is one of those where I had never seen this before, so I thought it'd be interesting to share with you all. Maybe you all already know what this is, but this is your audience response question of what is that device? Is it a retained sponge, a radiation therapy device, a lumpectomy cavity marker, or a medication delivery device? It's actually a lumpectomy cavity marker, and it's this bioabsorbable 3D marker. It looks like this spiral, and there are six titanium clips distributed throughout the spiral. The purpose is to mark the lumpectomy cavity to aid in radiation therapy planning. So the very first case I showed you had some surgical clips that the surgeon placed to direct the radiation therapist to the cavity. In this case, I guess it's a very unique and 3D look and supposedly helps with radiation planning. The interesting thing is it does gradually collapse over time, and so this is just from the manufacturer's website showing how the device slowly collapses down, and I have serial mammograms to show you how this looks on the mammogram. So it's kind of an unusual appearance. You can see that on the current study, which we read, it was almost just looking like a really dense bit of metal, and again, this is just for radiation therapy planning. It's not a device to deliver any partial breast radiation. So it's just there as a marker, and it's just one of those things that if you never... So the tip is if you don't know what something is, a great place to look is the op report. So if you can get an operative note and read it or ask the breast surgeon, but in this case it came from outside, so we had to look at the operative note because our breast surgeons aren't using this. So just a nice example of a marker collapsing over time. So thank you for your attention. Good afternoon, ladies and gentlemen. It's a great pleasure to have you here. So here is the outlook for the next 15 to 20 minutes. I will most likely present cases to cover the topic on implants, breast augmentation, and post-implant breast, and we will immediately start with the first case. It is a 52-year-old female. She has a screening mammography and implants since 10 years, and she has no symptoms. So what we do is to assess the breast, we perform mammography with and without the echelon technique, or also called push-back technique, to assess the implant as well as the breast by itself. So because of her breast density and because of the implants we performed an ultrasound of the breast, of both breasts, you see the left, you see the right, and based on some specific findings we decided to perform an MRI. So here you see T2-weighted images and T1-weighted images of the contrast media application. And I raise now the first question, what is the correct diagnosis of the, more or less of the implants? Do you see an intracapsular implant rupture of the right breast? Do you see an extracapsular implant rupture of both breasts? Do you see some gale bleeding, effusion, or a malrotation of the breast? And indeed the correct diagnosis was intracapsular implant rupture of the right breast. So what can we learn from this case? First of all, the role of mammography with respect to implants. So with respect to the screening, it's fine, you can do a mammography, which is good, but however, with respect to the implants, the role is limited. So of course we can see free silicon, which is not the way we want to see. We can see some bulging of the implant, indicating that we have to perform further tests like ultrasound or MRI, and we can of course also see capsular constructors, most indicating capsular fibrosis. Also we all know that capsular fibrosis is a diagnosis made by the plastic surgeons and not by the radiologists. So regarding ultrasound, we are doing much better because we can assess the implant if we see intracapsular ruptures or silicones out of the capsular. So we have several findings. This is the so-called keyhole or no sign. Then there is also very well known the stepladder sign or the subcapsular line sign. The subcapsular line sign is more or less explained that free silicon pushes back the implant line and invertedly so that you can see this subcapsular line sign. However, the most important technique regarding ruptures or implants, is MRI, where we can more or less learn from the literature that there exists several signs for intercapsular ruptures. It starts with the keyhole sign, it goes down to the subcapsular line sign, the linguine sign, and the salad oil sign. Based on these signs, we can also go back and score the degree of collapse. For example, in the keyhole sign, there is only silicone gel containing within the radial fold. It is called also a so-called uncollapse structure. In a subcapsular line sign, where more or less silicone separates the implant elastomer shale from the fibrous capsule, is more or less minimal collapse. However, if you see the linguine sign, then you have a partial to full collapse. Silicone gel has mostly entered there, more or less escaped from the implant, and proper to the intercapsular space. Also very important is the so-called salad oil sign, where you see droplets of fluid or gas in the silicone, which is always a sign of intercapsular rupture. In addition to that, MRI is perfect to assess the implant regarding extracapsular ruptures, as when we see this, when already silicone is more or less free in the parenchyma, so there must be a leakage from the fibrous capsule, as in this case, where you see a droplet of silicone on the outer layer of the fibrous capsule, better seen on the coronal fuse, indicating that this is free silicone. So let's move now, after these theoretical aspects, to a case where I show you several implants, and case A, two, C, and D, and you have now to count how many implant ruptures are you seeing. So do you see one, two, three, four, or five implant ruptures? And here are the cases. So start counting. Case A, case B, case C, and D. No, the right answer is four, okay? So most of you have done it. So let's now have a closer look to the cases. So this is number one, all agree. This is number two, I'm pretty sure that all agree. This is number three, everyone agrees, and this is number four, a silicone oil sign, okay? So now, you may say, why not five and six? So let's discuss this case with the question mark and this case with the question mark again. So case number two. What you see here are the two weighted sequences. On the left is quite simple. You see the subcapsular line sign. Some would say already linguini sign, but on the right side, you see funny lines, you know? Going through the implant on the right side, you see on the sagittal fuse, you see some dark lines. I show it again, and what you just saw is not an implant rupture. These are more or less folds, or in this case, so-called rupture mimics, which is very important to know. There are only existing two rupture mimics. One is the ghosting artifact, as in this case. It comes with movement either from the breast or from the heart, and another very important one is the truncation artifact, which is an abrupt interface change at the implant border. So what now with case number C? And this is a quite tricky case because what you see here are two envelopes. One envelope is carrying the normal implant. The second envelope, where you see the yellow arrow, is an envelope from the previous implant, which is now filled with fluid and seroma formations so that it is not an implant rupture. Are you happy with that? Cool. So, no? OK. Let's move to case number three. It's a 47-year-old female patient, and she had a prophylactic mastectomy with immediate implant reconstruction. I show you MR images after four and five years of surgery. She has no trauma history, and recently she feels something in her left breast. So what you see here are the images of 2020, T2 and STER images, and 2021. So what is the correct diagnosis of these two cases? Is this an intracapsular implant rupture? Is this an extracapsular implant rupture? Is this a gaital pleading? Is it a fusion or a malrotation of the implant? And these are the correct answers. It's a malrotation. So what can we learn from this case? Malrotation. Malrotation is rare. Nevertheless, some say we see it in about 14%. It's always linked to a minor trauma. This trauma leads to a disruption of the interface between the cavity and the implant, and this new capsule around the first capsule produces low friction between both. So, and then you can see rotations with 60 degree, 100, let's say 90 degree, or in this case, it's exceptional, 180 degree. So usually, as in this case from Korea, the patient immediately sees and feels it that there is a change in the contour of the breast. In her case, the minor trauma was induced by a port-a-cut implantation, which was not, you know, you can't see it in 2020, but within this period, she had a port-a-cut implantation, and this made, or is the explanation for her malrotation. By the way, if you have a closer look to these MLO views, based on the mammographies, you will not see the malrotation, okay? Let's move to case number four. She is a 37-year-old female, and you see, she's a medical doctor, by the way, and had a lump-size increase of the right breast over the last two months, and the implants are two years old. What do you see here? I show you T2-weighted images, T1-weighted post-contrast. By the way, there is no enhancement, and what I also show is ultrasound images of the lesion in the, whatever we see it, on the right breast, and T2 and T1 post-contrast. And I raise questions. Do we see an intracapsular implant rupture of the right breast? Do we see fibromatosis? Do we see hematoceroma formations? Do we see a breast implant-associated anaplastic large cell lymphoma? Or an extracapsular implant rupture of the right breast? The hematoceroma, which is correct. Nevertheless, what can we learn from this case? It's very important. Something regarding effusion, fluid and fluid correction around implants. These are two other cases. Whenever, you know, five to 10 mils is normal in asymptomatic patients. However, when you see more fluid around, like in these cases, final aspiration biopsy of the fluid is important. You have to collect the fluid. You have to send it to cytology in immunophenotyping to exclude lymphoma. When do we see these lymphomas? We see them usually at the earliest time point, one year after implantation. Or, in some cases, also as a strongly enhancing mass 10 years after implant insertion. Or you can palpable the mass, or you can see it on ultrasound. The risk to develop lymphoma varies. It's a certain uncertainty, as you can see, between 4,000 and 30,000. So, nevertheless, have a closer look to these two cases. In the upper row, you see effusion induced by the implant rupture. And in the lower row, on the left breast, you see huge effusion around the implant induced by a lymphocene. So, they more or less hurt the lymph vessels, and this leads more or less to this effusion. Good for the patient. So, in my last case, which is a 50-year-old female, I show you two MRI of the breast of different time points. So, you see the MRI of the breast in May 21, and in November 21, okay? So, I raise now the question, what happened in this time period? Do we see an intracapsular implant rupture of the right breast? Do we see post-surgical seroma bilaterally? Do we see post-surgical seroma bilaterally? And signs of fat grafting? Do we see a lymphoma? Or do we see extracapsular implant ruptures of the right breast? I show you again that the one way that after contrast media application of two different slices, I enlarge them that you can more go into the details. It was post-surgical seroma bilaterally, and signs of fat grafting. So, it's not really complicated to assess a breast after the implants were removed. Sometimes you see nothing. Sometimes you see effusions. Sometimes you see seroma formations. And maybe you can also see remnants of free silicone. But in this case, what happened is that the patient had, in addition to the removal of the implants, a fat grafting. And which brings me now to the topic of fat grafting. Fat grafting means that, you know, that the plastic surgeon takes out fat from any part of the body, centrifugize the fat, sometimes they do some secret stuff inside, and re-inject this to the breast. They started usually to improve the contours after surgery, so that you don't see any changes, as you see here in this case, before surgery and after surgery. But what we also learned, that in some instances, it produces a lot of mimics. Mimics induced, more or less, by a sort of inflammatory process due to fat necrosis, which leads to microcalcifications. So this is, you know, not easy, or let's say it's rather easy to interpret, but I show you other cases as well. However, the plastic surgeons become now very familiar, and it seems that this technique becomes very popular, and they do no longer do it only to improve the contour, but also to replace implant insertions. So no longer silicone implants, so rather to an increase of the breast by injecting free silicone, free fat grafting. So they inject up to 350 mils per breast, and impressively, the findings look superb. You see that the breast is increasing, it shapes the breast very well, you have better contours, and these are cases where they compared their new technique versus the implants. However, for us as radiologists, this can indeed lead to a lot of problems. And here you see several findings of post-fat grafting. Fat necrosis with and without microcalcifications, and it's sometimes not easy to interpret the microcalcifications, so you run into a biopsy. Sometimes it's very easy, sometimes you see fat necrosis and cystic areas in MRI, sometimes they look round like a cyst, sometimes like a complex or complicated cyst. So be careful and be aware what happened with fat grafting. So I come to an end. Many thanks for your attention. Okay, so I'm Jocelyn Repellier. I am coming from Washington, D.C. My task to you guys today was to just actually go over some cases talking about recurrent breast cancer. And so we will have probably just one question, and that's whether there's a recurrence or not, but we'll mainly go through a little bit of background. So the first thing overall, we have to think about recurrence as a topic. And if we think overall, it's about 19% chance of recurrence at 10 years, but that actually can be reduced depending on the therapy as well as the targeted therapy that we have nowadays. Looking at the guidelines on how we should be monitoring these patients, I would say mammography is probably still the gold standard. And that really has to do with the fact that we do have the randomized control trials that actually are telling us there's a decrease in breast cancer death with mammography surveillance. So the same guidelines actually pertain to that of women that wind up having a prior diagnosis of breast cancer, and that could be with or without DBT. So we know that DBT can improve our overall specificity and when it comes to the post-surgical changes around the bed, but it does have some caveats which we'll actually go through as well. So the one thing about the American College of Radiology is that they do recognize that patients in this category that have had a prior history of breast cancer are at slight increased risk, so the intermediate risk. So depending on their other risk factors, they may benefit from also going through bilateral MRI as well as ultrasound in order to improve sensitivity and surveillance of these patients. The overall focus, of course, whenever a patient has a known diagnosis is to make sure that we detect subclinical disease. So those women that are asymptomatic and also detecting local regional disease, not only within the ipsilateral breast, but also contralateral breast. So it's something that we don't wanna obviously forget about. There has been a recent meta-analysis that looked at the absolute breast cancer mortality reduction when there was mammography surveillance versus that of just clinical breast examination. And it showed a reduction, about 17 to 28% of the recurrence when you wind up having mammography surveillance. So some of the pitfalls, I think Dr. Jo actually went over really nicely that we have to worry about when we're looking for recurrence is really that we do have limitations when it comes to that of mammography. We know that mammography is an imperfect tool, but it's not only that limitation, it has to do with the evolution of what we're seeing from the post-surgical change. So that is really quite heterogeneous, but in addition, we have those structural changes which she talked about as well as post-radiation changes and skin changes, in addition to parenchymal changes as well. And sometimes that can be a little bit confounded by post-operative hematomas or seromas in addition to fat necrosis, which we know is an evolution. So the one thing that can also be a little concerning are the dystrophic calcifications that occur within the scar itself. And they do start off small and can be quite heterogeneous, but for the most part, we try to look at the features of them after further workup, determining whether we could put them in a short interval follow-up or whether it's something that we would have to go ahead and biopsy. Women that are diagnosed with breast cancer and utilizing mammography as well as DBT, there have been some studies that looked at the reduction and the indeterminate findings that we might see, particularly with that post-surgical change and post-radiation changes. And by adding DBT, it can actually reduce that from about 6.9% to about 4.9% in this one study, which was statistically significant. But the common theme that we see with DBT as we get higher in the breast density, so those women that are extremely dense, it's not as robust as those women that are less dense. And so we also see the same thing with women that have specifically had surgery as well as radiation to the breast. In these patients, you may have to add additional supplemental evaluation with either MRI, and if the patient can't go through MRI, maybe bilateral ultrasound. So we are gonna go through some cases, and our first case is this patient here. She's a 65-year-old female. She complained of pain, and a biopsy was performed. You can see that there is a mass in the six o'clock axis of the right breast. It's somewhat irregular in appearance. It's hyperdense, and the adjacent ultrasound just shows that there is a microlobulated mass, somewhat irregular actually, angular I should say, in certain areas with internal vascularity. This unfortunately came back as a triple negative breast cancer. Triple negative breast cancer is about 15% of all subtypes of breast cancer, and it is unfortunately associated with a worse prognosis compared to those patients that have different other subtypes. But what it also tells us as those that work with patients with breast cancer is that they may also have a higher rate of recurrence, particularly in the first couple of years after diagnosis. So this is her MRI at the time of diagnosis. We have our T2 weighted, as well as our T1 axial post-gatilineum, and then also our T1 sagittal post-gatilineum image. And so we can see that there's a rim-enhancing mass. It also demonstrates hyperintensity on T2 weighted images, and we have a nice plane if we look towards the posterior and the retromembrane fat near the test wall, which is a good thing. But most patients that wind up having triple negative breast cancer because of its more aggressive nature wind up having neoadjuvant chemotherapy. And so when we do evaluation of the patient after neoadjuvant therapy, what we're looking for is to make sure that there is an initial response. And that really acts as a surrogate for us in order to determine whether the patient's gonna have a better prognosis. So we can see to the left, the unilateral mammogram on the right, where you have the same area that we previously saw on the pretreatment, where it has decreased in size and also a little bit of density. It does have our little surgical clip, I mean, our biopsy clip in the center, as you can see, showing that we did biopsy that one area. And this is actually at six months. We actually also do a six-month follow-up. And ours is actually the first year after the patient is diagnosed. We do two six-month follow-ups and then we actually convert her back to a year. But this is the first six months after her surgery. And you can see in that same area where she previously had her triple negative breast cancer, that there is some architectural distortion and some asymmetry. And Dr. Jo actually showed us what normal actually looks like. And so in this case, she was also having some pain. So we did do an ultrasound and she was fine in that regard. But she also complained of a little bit of thickening as well. And we couldn't really see anything that was associated with it. But then you see at the 12-month mark, so the one year after diagnosis and after her treatment that she had, that you can see that there's an increase overall in the density where you previously had the scar from the lumpectomy site. So if we look overall from the six-month mark, let me just find my, there we go. So if you look overall at the six-month mark compared to that of the 12-month mark, we can see that there's overall increasing asymmetry as well as density. And also maybe even some volume that's associated with it. And this would be considered suspicious. So that's one thing that we do wanna make sure that we're not actually just chalking everything up to post-surgical change, but that when you start to see an increasing asymmetry or a developing asymmetry, that that is really quite suspicious. So we did do an ultrasound and on the ultrasound, you can see there is a mass that is adjacent to the scar. We can also see that there is enhanced through transmission of this hypochoic mass and she was biopsied and unfortunately it did come back as a triple negative breast cancer once again. So that was after one year and this is just her MRI that she wound up having during that time. Given the appearance of what it looked like, it was a question as to whether there was involvement in the chest wall. And you can see that there is enhancement. There's a rim enhancing mass and there's also, in addition to that rim enhancing mass, there's also probably a rim enhancing mass that's just adjacent to the larger one that you can see. And then on the sagittal T1 post-catalyneum images, you can also see that there is involvement with enhancement of the muscle as well. So this patient went on to have a mastectomy and so far is still doing well. So our six month mark, we did get an MRI. As I said earlier, she did complain of some thickening and we were a little concerned. The only thing is is that when you actually wind up doing an MRI at such an early stage, it could be because of the confounding variables of healing as well as the post-surgical change, something that could be a conundrum for the interpreting physician. So even with that though, there was no evidence of significant enhancement at that area. This is the subtraction axial post-T1 image as well as the T1 sagittal all the way to the left. But then you can see on all the way to the right at her one year mark when she wound up complaining of the new lump that it was a recurrence. So something about breast cancer recurrence, some of the things that you should think about. By definition, it's in the ipsilateral breast with similar pathology to that of the initial breast cancer. And then you can have it at the surgical site or within the same quadrant. The position nowadays can be a little bit more variable given the different surgical techniques that we actually wind up having. And because of cosmesis, some of the surgical techniques as well. But some things to learn from this is of course, increasing density warrants additional evaluation. And thinking about particularly the subtype of the tumor itself, triple negative breast cancers, they do have a higher risk of immediate recurrence. Some of the things that we have to worry about though, MRI evaluation can give us a confusing picture sometimes depending on the therapy that the patient wind up having. So moving on to case two. This is a 55 year old female. She came in with a palpable lump and she had a DBT examination. We do synthetic, we do everything DBT and use a synthetic view. And so you can see that there is a dominant mass in the right upper outer breast and the posterior one third of the breast. But then there's also a little bit of an abnormal lymph node. And addition to multiple areas that are coming back in the upper outer right breast where she has these irregular masses. On spot tomosynthesis, you can see that those areas persist almost in a segmental distribution. We did an ultrasound and an ultrasound shows that there were multiple masses that were corresponding similar in appearance to that of the mammogram that were irregular as well as demonstrating internal vascularity. And then we also see a lymph node that has a little bit of eccentric thickening as well. And we biopsied her and that came back as an ERPR, her two positive cancer. She could not go in to have an MRI, but we also do alternative for our patients, BSGI. And you can see that there's the same segmental distribution on the BSGI as well. So here you have the radiotracer uptake correlating to that of the mammogram as well. But then you can also see that there is a positive lymph node up in the axilla. And so this patient, if we think about luminal B cancers, they too are a little bit more aggressive. And this was three years later. Because of the tumor burden, she wound up having a mastectomy and autologous reconstruction. And then she was feeling a palpable lump, unfortunately in the same breast and near the axillary tail. Most of the recurrences that you're going to get are gonna be more superficial. Most of the patients wound up feeling their lumps because of the minimal amount of breast tissue that's still in the subcutaneous area, but also towards the edges. And it could potentially be deep within, near the muscle as well. And so, luminal B cancers, as I said, are a little bit more aggressive on their subtape because of the KI-67, the inflammatory component. They too have a higher rate of recurrence compared to those that are the non-luminal. And if we look at the uncertainty of how we should be evaluating these patients, particularly with autologous reconstruction, there are some minimal data that has retrospective studies that look at using mammography for these patients as there has been some cancers that have been identified using mammography surveillance in these autologous reconstructions. The recurrence, as I said, is mostly superficial. And most of these patients come in with palpable masses or complaints. And that could be secondary to a majority of benign findings, but it could also be due to a recurrent cancer as well. So just, again, things to think about. Although most of the breast tissue is removed in mastectomy when you have reconstruction, there still may be residual tissue and the patients can get recurrent disease. And as I said, there is limited published data offering evidence that suggests a benefit from mammography screening of autologous reconstruction in these patients. Some of the things to think about, anything that is symptomatic, the patient should have additional evaluation of those palpable or painful symptoms. So moving on to the next case, case three, this is a 33-year-old female with a grade one invasive ductal cancer. I have an arrowhead over the far posterior and one third of the breast superiorly where there's a little bit of asymmetry. On DBT, it actually showed a little bit of distortion and I have the adjacent ultrasound here, as you can see, an anti-parallel mass that correlates to that area that we see on the mammogram. And so this patient was diagnosed with a grade one invasive ductal cancer and she came back again three years later. It seems like there's almost a common theme here with a new palpable mass. You can see on her MRI examination that she winds up having some enhancement right where she had her scar from her prior lumpectomy surgery. Ultrasound was performed and on the ultrasound, you can see that there's subcutaneous kind of hypochoic irregular mass. There is no evidence of internal vascularity or increased vascularity, but for new symptoms, this was biopsy. Unfortunately, that too came back as an invasive ductal cancer, similar to her previous cancer. And you can see how on this radial view, how close it is to the surgical scar. So her surgical scar kind of dips down right here and then here's the skin right here and you can see this is actually where the new recurrence is. And so in this patient, you know, if we think about it, some of the things that we could learn from is that women, particularly that are premenopausal when they're diagnosed, that maybe we should be doing additional screening in these patients. And that's one thing that the American College of Radiology actually recommends being that they do have a 20% risk of another breast cancer because they have, you know, many more years to actually live. And so we wanna be able to, again, pick up cancers, you know, at their earliest stage so they have a better prognosis. And so the one of the last case was just kind of a combined case. So this is a multicentric cancer. So a significant amount of tumor burden. This was an invasive lobular cancer and ultrasound shows that there are multiple masses in the upper outer right breast. This is just showing you other static images where I've kind of circled the centimeter difference from the nipple, one being four and the other one being almost 10 centimeters. So a pretty big swath of tissue that was actually involved. She had an MRI and on the MRI, it just shows you again on the axial T1 subtraction views that there is probably a larger cancer, you know, more of an index cancer and then other additional cancers that are satellite lesions that are adjacent to it. And so looking at her sagittal, you can see that's probably the largest one that we could see on the axial and really, unfortunately, she had more disease when she wound up having her mastectomy. So she went on underwent a mastectomy and then unfortunately, within a year, she actually wound up feeling a new lump. And so you can see that there's an irregular hypochoic mass that is anti-parallel in position. This was biopsied and it came back as a diagnosis of invasive ductal cancer. So I have next, you know, to the left here, four years previous where she had her cancer, which was involving the entire upper outer breast, as well as kind of coming over towards the medial half and then her undergoing the mastectomy. You can see where our clip is and she had the mastectomy here. So the question is, is, you know, whether this is a recurrence or not as a diagnosis was IDC. So is it a recurrence or is it not? So majority of people are saying no, and that is the correct answer being that it is, although it's in the same breast, it is of a different pathology, okay? So it was invasive ductal when we had the second cancer and the first cancer was an invasive lobular cancer. And so this is actually another patient with invasive lobular that really her initial presentation was a breast mass diagnosed with multicentric invasive lobular cancer. You can see that she did have neoadjuvant chemotherapy and she had mastectomy and axillary dissection, but she unfortunately was lost to follow up and then she returned seven years later and you can see this large, really necrotic heterogeneous mass that's invading the sternum and eroding into the thoracic cavity and wrapping around up towards her axillary arm through the lymphatic vessels and the vessels. So the one thing that I do wanna actually show you is that she also has a contralateral heterogeneous mass as well that was not necessarily contiguous with her recurrent disease. And if we think about this, she was biopsied, both areas actually were invasive lobular. You can see the ultrasound on the bottom here of her native breasts and you can see that all the heterogeneous areas and the lobular proliferation that you wind up seeing, which is typical of invasive lobular. But right now, this is just the take home point that clinical breast examinations after mastectomy are really the only guideline that we wind up having at this point. And it's kind of the mainstay. And so, are there in the future potential other things that we could do for some of these patients? So in summary, breast cancer recurrence, ipsilateral breast cancer, recurrence of similar pathology to that of the initial diagnosis and recurrence in the reconstructive breast may occur in residual tissue that is superficial or deep towards the chest wall. And additional imaging tools may be helpful to evaluate recurrence in symptomatic patients, particularly those that are young women and those that wind up having very dense tissue. And with that, thank you.

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